For some in Israel's mental health system, more budget cuts mean paralysis

Although one in four people will need psychiatric health care in their lifetime, local facilities catering to them are facing stringent cutbacks.

After studying data recently released by the Bank of Israel, Prof. Joseph Zeira says that while the output of workers in the business sector rose by 20 percent between 1999 and 2011, their wage levels did not actually change.

Zeira, from the Hebrew University of Jerusalem's economics department, presented these findings on Monday evening at a Tel Aviv event held to launch the publication of "Efshar Gam Aheret" ("It Can Be Done Differently" ), a collection of reports prepared by the alternative socioeconomic committee created during last summer's nationwide protests. Just a few hours earlier, the government had approved a proposal by the Finance Ministry for a budget cut and a hike in taxes to raise NIS 14.4 billion for state coffers.

Many argue that nothing works more powerfully to aggravate social inequality than the imposition of indirect taxes such as VAT. According to a report prepared last year by the Knesset Research and Information Center, indirect taxes constitute 44.2 percent of the net monthly income for a family in the bottom 10% income bracket. By contrast, persons in the top decile spend just 11.5 percent of their net monthly income on indirect tax payments.

During the last two years, the state accrued more revenue by indirect taxation than by direct tax mechanisms. As far as the Netanyahu government is concerned, options to raise corporate taxes, or windfall taxes, were not viable. Social protest against the budget cuts and tax hikes is likely to arise anew tomorrow night.

"The government of Israel is intent upon supplying the oxygen needed to revive the protest movement," reflects education professor Yossi Yonah, who, together with economics Prof. Avia Spivak, headed last year's alternative experts committee.

Zeira, who was also on the committee, says that direct taxation instruments should have been used by the government, rather than the indirect VAT. Yet, as he points out, it is worth noting that "for the first time, the government has decided to reduce a significant portion of the deficit by raising taxes rather than cutting back on social welfare expenditures. It has become clear that these cannot be cut - and that recognition comes as a victory for the protest movement."

Hardest hit

The proposed budgetary cuts leave a particularly big question mark with regard to the quality and scope of services provided by the Health Ministry. Patients who suffer from ailments but are not represented by a Knesset lobby or by militants in the street could be seriously affected. One such endangered group are the mentally ill.

Early in the week, the cut in the Health Ministry budget for 2012 stood at NIS 18 million. A bit more than half this figure, NIS 9.4 million, was to come from scaled-back development plans for hospitals. While a subsequent, intensive lobbying campaign on behalf of Ashkelon's Barzilai Medical Center did succeed, for example, to ensure funding for improvements in its emergency room, the budget cuts remained in full force with respect to psychiatric facilities.

Health Ministry officials say that cutbacks in allocations to the health system in past years created a deficit of NIS 230 million in hospital development programs. The directive to focus on slashing allocations to this area came straight from the Finance Ministry, these officials contend.

"The cuts have created a kind of paralysis," says one senior health official. "We can't keep our heads above water."

Abarbanel Mental Health Center, Bat Yam, might be the hardest-hit mental health facility in the country. Officials from the health and finance ministries were aware of Abarbanel's eroded service infrastructure as early as the late 1990s. In recent years, the facility has been the subject of a number of reports in various media outlets.

The government proposed to close Abarbanel in 2003, but that decision was not implemented, owing partly to delays in the formulation of a reform plan for the national mental health system. Though it has remained in operation, the Bat Yam facility has not received a single shekel for development in nine years. The building in which the unit for autistic youth is housed was built in the 1940s. It has an asbestos rooftop - "So long as the roof does not erode, it can continue to be used," workers explain.

Each room has three beds and two small cupboards. The walls are peeling in many rooms, the beds are rusty. A frustrated lament: "If this is what heaven looks like, then what does fucking hell look like?" is scratched into one of the walls. Twenty-seven young people are residents in the unit, and some of them have been in it for prolonged periods.

The unit for chronic sufferers of mental illness has 30 adult patients. It features three shower stalls, at the end of a corridor. Mold crawls around the walls. "This place is not worthy of human habitation," moans one nurse. "We are told that nothing here deviates from required standards. Whoever formulated such standards should try living here."

Things fall apart

"These aren't acceptable standards in the 21st century," acknowledges Abarbanel center director Dr. Yehuda Baruch. "We have some units where conditions are worse than those found in prisons. Many patients have no other options. About half of the residents are compulsory patients and don't even have the option of saying they want to go home. There is absolutely no doubt that care for patients is impaired." Some 300 persons are under care at this facility.

Abarbanel's annual budget is NIS 100 million. About 85 percent of that is directed toward wages; the remainder goes to medicine, food, transportation, security, utilities and city taxes.

"Everything keeps falling apart and we keep patching things together, until the next catastrophe," Baruch reflects.

Air-conditioning units are never switched on before May 15, no matter what the weather is like before then. The number of patients who stay at the facility on a given weekend is calculated, to ensure that no expenses on food are wasted. In the absence of a development budget, any repair made is budgeted at the expense of something else. "Budget sources have dried up, because everyone expected that the medical center would be shut down soon. In terms of care conditions, we have operated between life and death here for about a decade," decries the medical center's deputy director, Dr. Moti Mashiach.

The 2003 decision to shutter Abarbanel was never formally revoked. Nonetheless, last year the health ministry approved a plan to improve the youth unit and autistic patient unit. However, Baruch says these renovations are pending, and depend upon approval from the local planning and construction committee. Right now he is worried about a scenario under which the renovation plans would be approved, but concurrently the health ministry would approve the cutbacks in the hospital development budgets. Consequently, there would be no money to carry out the improvements in care facilities for youths with mental health issues.

Prof. Nadav Davidovitch, from the health systems management department at Ben-Gurion University of the Negev, says Abarbanel's circumstances are an "extreme test case of public health care neglect. The large hospitals manage to bypass this neglect by instituting private care services and raising donations, but such steps are not taken as easily by medical centers on the periphery, which sometimes have no psychiatric institutions at all."

Studies here and overseas indicate that one out of every four persons needs mental health care at least once in his or her life. Mental health illness, along with heart disease and cancer, are the three most widespread forms of ailments known to health establishments. An analysis prepared by the health team in the Yonah-Spivak committee discloses that only 5.5 percent of Israel's health budget is slated for mental health services. In many areas, particularly on the periphery and in Arab communities, such services are virtually nowhere to be found.

The finance ministry says in response: "There is no intention to cancel plans for infrastructure improvements in mental health centers. The health and finance ministries have rated this sphere as a top priority. Within the 2011-2012 budgets, the finance ministry allocated NIS 100 million for infrastructure improvement." This allocation, notes the treasury, is supplemented by an NIS 300-million investment in public health clinics, made within the mental health system reform plan.

Health Ministry officials sound less optimistic. "Budget allocations for infrastructure improvement were promised in the past, but these do not cover deficits," an official warns. "You can't carry out new projects when deficits are so large. This is just the start. In the 2013 budget, there will probably be more cutbacks."